More is not better
The American College of Sports Medicine (ACSM) is the country’s most credible voice on the power of exercise for good health. The ACSM and its member professionals (including me) are routinely on the leading edge of the best evidence-based advocacy for exercise as the essential lever for both sports performance enhancement and chronic disease risk prevention and management. ACSM peer-reviewed journals are the best in the business.
Imagine my chagrin, then, when I received in yesterday’s mail a promotional flyer encouraging ACSM members to get ultrasound screening for cardiovascular disease (CVD) from LifeLine Screening. I guess that the fealty to evidence only applies when positioning yourself as the “expert” , but not when pitching unsubstantiated (and probably money-making) fluff to the membership.
The brochure’s headline pitch is that ultrasound screening of the carotid arteries can help to “prevent cardiovascular disease and sudden stroke.” Let’s start with some fundamentals:
- Screenings don’t “prevent” disease in most cases; they typically find incipient disease or risk factors, which may or may not merit treatment, depending on the person’s constellation of risk factors. Healthy adults with no symptoms and few or no risk factors are almost certainly not likely to benefit from mass screening…for almost anything.
- There is no nuancing of the recommendation. Routine ultrasound screening of the carotid arteries in healthy adults was rejected by the US Preventive Services Task Force in 2008.
- The USPTF also reported that screening for aortic aneurysm is not evidence-based in adults without risk factors or a history of smoking.
- A further study of ultrasound screening of the carotid arteries, done at NYU’s Langone Medical Center, concluded that it has value in adults with evidence of ventricular dysfunction.
- In the Choosing Wisely initiative of the American College of Physicians (ACP), the American College of Cardiology and the ACP reject enhanced imaging for CVD in patients without symptoms or significant risk factors. (They don’t specifically reject carotid artery ultrasound, but it is unclear from the writing whether it is or is not subsumed in the category of “advanced imaging.” Even if it is not, what’s clear from the procedures they caution against is that screening generally healthy adults is frowned upon.)
- There is no discussion of outcomes. Finding disease is not an outcome. Demonstrating that finding the disease altered treatment decisions or the trajectory of the illness are outcomes.
- There is zero acknowledgement of false positives and their adverse impact.
- There is no disclosure of the financial relationship between ACSM and LifeLine. As a dues-paying ACSM member, I want to know how much money the organization may make through the promotion of unnecessary medical care, during an era when there is a critically important debate over whether more medical care is necessarily better medical care. If you doubt the value of this proposition, read Know Your Chances and Overdiagnosed.
- There is no disclosure of the fact that these screenings likely are not reimbursable by a health plan, which is a strong indicator that they are largely commercial in nature, not clinical.
- Last, but not least, it is highly likely that these screenings are mostly irrelevant to the ACSM member population. I think that it is safe to stipulate that ACSM members are likely younger, healthier, and fitter than the general population. According to the CDC, stroke prevalence in people over age 65 is more than double that in people under 65; in other words, it is a disease primarily of aging (and poor health habits). Why promote screenings of dubious value to people who are supposed to be leading the way for the rest of the country?
Membership can be hazardous to your health
This is embarrassing. When you aspire to excellence and leadership, your adherence to the critical principles that frame your aspirations must be unassailable. You cannot stand before the nation and exhort employers, governments, and individuals to follow your evidence-based strategies and then turn around and entice your membership to participate in a game of clinical trivial pursuits. ACSM loves to brag about how its leadership appears TV and cavorts in Washington with the First Lady and Congressional leaders, such as they are. You are either all in for evidence and disclosure or you are just a politician. And, really, don’t we already have enough of those?
I invite responses from the ACSM.
Addendum, June 20, 2012:
My blog post of June 19 drew a prompt and highly professional response from ACSM. Both CEO Jim Whitehead and Senior Director of Communication and Advocacy Dan Henkel communicated with me throughout the day, moving quickly to find out what happened and why. Henkel assured me that the letter was mailed in breach of ACSM’s “own protocol for reviewing communications about the affinity program, which offers discounts as a member benefit.” Further, both gentlemen made clear that a promotion letter such as this one would never again leave ACSM offices and that the organization is moving to improve internal controls in that regard.
As an exercise professional, it heartens me that the leadership of my College takes these kinds of criticisms seriously and reacts to them in a manner that is both very reasonable and responsible. ACSM may have erred in sending the letter, but, in my view, they have set a high standard for organizational behavior by acknowledging such and moving to prevent further events.